Community Regional Medical Center in Fresno has been fined $86,625 for a towel being left inside a patient for three months after an abdominal surgery.
The state penalty is the hospital’s fourth issued by the California Department of Public Health since 2007.
In the most recent case, state investigators said a patient had to have a second surgery to remove a “blue towel” that had been left in his abdomen after removal of his bladder and prostate on April 8, 2014.
According to the state report, the patient had an X-ray after the surgery because of an incorrect scissor count, but it did not show any foreign body because the towel was not visible on an X-ray.
The state said the hospital did not have a procedure in place to count “blue towels.” According to both the director and manager of surgical services at Community Regional, the towels had never been a countable item in the operating room and “were only available for surgeons to dry their hands after scrubbing in, or to drape on a patient, not to ever be used internally.”
The director and manager were quoted in the report as saying the operating room staff was “devastated” upon hearing of the incident. The director of surgical services said no one recalled the towel going into the body, but “the towel was obviously overlooked because what goes in is supposed to come out, and that did not happen in this case.”
When hospitals are penalized, the state requires the institution to provide a plan of correction. Community Regional has since ordered that all surgical towels be counted in the operating room.
“As a result of this regrettable incident, we completed corrective steps that were approved by the state and included a thorough investigation of our policies, adjustments in our procedures and appropriate training of our staff,” said Michelle Von Tersch, vice president of corporate communications for Community Medical Centers.
Community would not comment on whether the operating room nurses and staff were disciplined or whether the surgeon continues to operate at the hospital.
The state does not identify patients because of confidentiality laws, but the patient told investigators he lost 43 pounds within a month of the abdominal surgery at Community Regional. He had no energy, no stamina and said, “I felt like I might not live.”
At a follow-up visit to the surgeon about two month after the surgery, a scan of his abdomen was ordered and he was told it showed an “abdominal mass.” The patient said he was frightened that he had cancer.
The patient was referred to another doctor and had surgery on July 7. The towel was discovered during that surgery.
The state said Community’s failure in this case “resulted in preventable pain, emotional and psychological suffering, injury and harm.”
Under a 2007 law, hospitals are required to self-report errors in cases that could cause serious injury or death. Community was one of eight hospitals in California to be penalized by the state this month. Penalties totaled $483,650.
Community Regional and Saint Agnes Medical Center in Fresno have had four penalties issued since the 2007 law. Fresno Surgical Hospital has had two penalties and Kaiser Permanente-Fresno and Clovis Community Medical Center have each had one.
Penalties carry a fine of $50,000 for the first violation, $75,000 for the second and $100,000 for the third or subsequent violation. After three years, the penalty clock starts over.
In 2012, Community Regional was fined $50,000 for a 2010 incident in which a woman was given a lethal overdose of a blood-thinning drug.
In 2013, the hospital was fined $175,000 for two cases in which patients were harmed, including one in which cardiac surgeon Dr. Pervaiz Chaudhry was said to have left the operating room during an open-heart procedure, leaving a physician’s assistant in charge. Chaudhry has filed a $15-million claim against the state for the report, which he says was inaccurate.